The Challenge
Your health care depends on who you are. Race and ethnicity continue to inuence a patients chance
of receiving many specic health care procedures and treatments. A thorough review of health quality
data shows that racial and ethnic minorities continue to receive lower-quality care than Whites. These
differences persist even when insurance status and socioeconomic factors like education and income
are taken into account. In its 2012 National Healthcare Disparities Report, the Agency for Healthcare
Research and Quality suggests that disparities in quality of care are common.
Changing demographics make addressing these inequalities urgent:
A changing population: Racial and ethnic minorities represent about one-third of the U.S.
population and will become the majority of the population by 2043.
4
What Were Learning:
Reducing Disparities in the Quality of Care for
Racial and Ethnic Minorities Improves Care
Issue Brief
Equity
NUMBE R 4
J UNE 2 0 1 4
AF4Q is the Robert Wood
Johnson Foundations
signature effort to lift the
overall quality of health care
in 16 targeted communities
across America. These briefs
distill some of the key lessons
learned by these regional
alliances of providers,
patients, and payers as they
work to transform their local
health care and provide
models for national reform.
Aligning Forces for Quality
Quality Field Notes
Blacks received worse care than
Whites, and Hispanics received worse
care than non-Hispanic Whites, for
about 40 percent of quality measures.
1
40%
American Indians and Alaska Natives
received worse care than Whites for
one-third of quality measures.
2
33%
Asians received worse care than
Whites for about one-quarter of quality
measures, but better care than Whites
for a similar proportion of quality
measures.
3
25%
$60B
The cost of disparity: Excess costs
associated with disparities in health were
estimated at $60 billion in 2009.
5
Inequities in health not only create a tragic human burden in shortened lives and
increased illness, they also create an economic burden:
2043
2
Improving equity
involves data, it
involves training staff,
and it involves actual
execution through
interaction with
patients. The REL data
collection effort weve
done here is a small
demonstration of how
all of those pieces can
be achieved and how
difcult it is to achieve
that work across a
region. It takes time, it
takes diligence, and it
takes a willingness for
systems and providers
to work cooperatively
for the good of
patients. Thats what
our equity work has
taught us.
LISA SLOANE,
CONSULTANT TO THE HEALTH
COLLABORATIVE, CINCINNATI
Whats Working
Reporting Leads the Way. In order to reduce disparities in care, organizations and regions must rst
understand where disparities exist, the scope of the disparities, and the root cause of these disparities.
Unless measured, disparities in care can go unnoticed, even as organizations seek to improve care.
Data transparency is beginning to have an impact in many AF4Q communities where access to data
stratied by race, ethnicity, and language (REL) has spurred organizations to recognize areas where
disparities exist and to take action. What gets measured gets managed. AF4Q provided intensive
technical assistance to support the collection of REL data in hospitals and clinics. These efforts raised
awareness of equity as a key component of quality and drove more in-depth analyses of disparities in
care.
In Cincinnati, the Health Collaborative invested heavily in getting REL data collection off the ground,
and the result is consistent, actionable, exchangeable data about differences in care. Early on, the
group focused on getting every afliated hospital in the region to agree to report the same categories
for race and ethnicity, and trained registration staff in patient self-reporting methodology. Launching
REL data collection regionally took three years, and was capped by We Ask Because We Care, a
public-facing campaign that introduced the rationale behind this new kind of reporting. The public-
facing campaign was very helpful, recalls Lisa Sloane, a consultant to the Health Collaborative.
What we found was that while you may get a patient here and there who does not want to answer
questions, what you have for the most part is registration staff who feel uncomfortable doing
something new. Once people got comfortable with REL data collection, it became second nature.
For Sloane, the most important lessons include the value of involving health system IT departments
and making sure coding and categories line up across systems. Training across systems, validating
the integrity of data, and planning for sustainability required extensive collaboration between
organizations. Like the rollout of REL data collection, the insights and changes made possible by the
data are emerging over time. Thus far, the data show pockets of disparity in the region in terms of
overuse of the emergency department. Clinics and health systems are analyzing their own data, and
Atrium Medical Center has added an equity category to its public report cards.
Minnesota Community Measurement (MNCM) has published health care disparities reports for the
Minnesota Department of Human Services annually since 2007. What began as a state-level effort to
report on the Healthcare Effectiveness Data and Information Set for patients enrolled in Minnesota
Health Care Programs compared with those insured by other purchasers has, with support from
AF4Q, expanded to include wider, clinic-level reporting of race-stratied performance data. Before
this report became available, national and state-level reports of differences in care were available,
but information wasnt presented at an actionable level. MNCMs report supplies objective data and
brings accountability to medical groups and clinics, allowing them to reect on their own disparities
and identify areas for improvement within their systems. Anne Snowden, MPH, CPHQ, director of
performance measurement & reporting at MNCM, is particularly proud of how Minnesota clinics
have rallied around the report and voluntarily submitted data on race, ethnicity, preferred language,
and country of origin. In highlighting related equity/disparities reporting initiatives, Snowden noted,
You dont need a state mandate to get community buy-in. You need perseverance and community
Identifying and acting to reduce disparities in care for racial and ethnic minorities has been a core goal
of Aligning Forces for Quality (AF4Q) since its inception. In communities across the country, diverse
stakeholders are at work sharing data, encouraging collaboration, and making patients and consumers
part of improving quality for all.
3
Having leadership for
all the different health
systems in the region
involved makes it
easier to make changes
that have impact. It
makes it easier to say,
Lets share what we
are doing in a way that
is collaborative rather
than competitive.
Thats important in any
quality improvement
work, but that
commitment is
especially important in
reducing disparities.
SHARI BOLEN, MD, MPH,
ASSISTANT PROFESSOR OF
MEDICINE AND PROFESSOR
OF EPIDEMIOLOGY AND
BIOSTATISTICS, CASE
WESTERN RESERVE
UNIVERSITY; PHYSICIAN,
DIVISION OF INTERNAL
MEDICINE, METROHEALTH
MEDICAL CENTER, CLEVELAND
champions and the diligence to keep it going. Though some gaps in the core measures included in
the Health Care Quality Report are narrowing, each report continues to identify nuanced areas of
inequality. In addition, MNCM is currently leading an effort to bring together eligible clinics and
community health workers to help address community-level diabetes disparities through customized
tools and trainings on chronic disease self-management.
Like MNCM, the Washington Health Alliance has begun by basing its disparities reports on Medicaid
data stratied by race, ethnicity, and language. The Alliances Disparities in Care 2013 Report reveals
that Medicaid enrollees receive lower rates of effective care compared with commercially insured
populations across a number of quality care domains and diabetes care showed larger areas for
improvement among Hispanic/Latino populations and American Indian/Alaskan Native populations,
when compared to other racial/ethnic groups. The Alliance advocates for engaging providers,
consumers, and community agencies in improving Washingtons disparities results. The Alliance
activates providers through private medical group-level Disparities in Care Reports and through
convening medical directors to discuss improvement strategies. Already, the report has gained the
attention of key stakeholders, and it is the Alliances hope that the report will serve as a call to action
and a foundation for more targeted and effective quality improvement efforts that incorporate equity
throughout the state. In several states, local reports on health care equity are serving as tools that drive
the development of policy and priorities at the state level.
Moving From Data to Action. The inherent structure of the AF4Q initiative is a major strength of its
approach to disparities reduction: multistakeholder coalitions of consumers, providers, and payers are
vital to reducing regional health and health care disparities. In community after community, they have
made clear that disparities are unacceptable and must be prioritized. Because disparities are the result
of complex interactions, collaboratives can help provide technical assistance, establish practice-level
patient and community advisory boards, and nurture partnerships between practices and community-
based organizations.
Better Health Greater Clevelands efforts to move the dial on blood pressure control among Black
patients is an example of such efforts. A demonstration project that brings a communications
curriculum and treatment algorithm to the clinics working to improve blood pressure control is
being supported by and deployed at clinics belonging to the four major health systems in the region.
Bringing a wide variety of partners to the table has made Better Health a powerful convener.
Greater Boston Aligning Forces for Quality is collaborating with the Boston Public Health
Commission to pilot the Health Equity Dashboard that will offer a better understanding of health
disparities regionally, while it simultaneously provides data to underpin the alliances Healthier
Roxbury initiative. Focused on one of Bostons most ethnically diverse neighborhoods, Healthier
Roxbury brings together a broad set of community-based stakeholders to tackle disparities in
key health care measures such as emergency department visits for children with asthma and
hospitalizations for adults with diabetes.
4
Patients at the Table. A patients cultural background inuences both their experience of care and
their health behavior.
6
Understanding each patients cultural identity is necessary for effective care.
7
A handful of AF4Q communities have been working with experts from Finding Answers: Disparities
Research for Change and the Center for Health Care Strategies to identify and act on disparities in
the populations they serve. In several communities, the Equity Improvement Initiative has resulted
in demonstration projects designed to bring patients and communities to the table to help design
programs to reduce disparities. Enabling patients to voice their concerns and identify challenges has
helped change the approach to chronic disease management in several locales. The Greater Detroit
Area Health Council is adapting a model tested by Finding Answers that makes local patients stars
in patient education videos focused on addressing the challenges of living with chronic disease. Such
peer-to-peer storytelling has been shown to have a marked effect on patients ability to adhere to
recommended treatment and lifestyle changes as well as patients actual health outcomes.
8
Work that brings patients to the table to create solutions for diabetes self-management has been
particularly widespread. In Cincinnati, Crossroad Health Center, part of the Health Collaborative,
identied a disparity in blood sugar control among Spanish-speaking patients with diabetes. They are
working with a Spanish-speaking nurse who is a former patient advocate to address barriers to self-
management among this group. In Buffalo, the Jericho Road Community Health Center (formerly
Jericho Road Family Practice), part of the P
2
Collaborative, is working with groups of Somali patients
to design an intervention that will help Somali patients live better with diabetes. Already, Jericho
Road is working on helping these patients gain better access to exercise and community support. The
health center has partnered with the local YMCA to provide low-cost exercise classes to their Somali
patients, on-location at the Jericho Road and according to patient cultural preferences, in gender-
separated sessions. In Wisconsin, Wheaton Franciscan Healthcare gained understanding of the root
causes of poor outcomes in diabetes among Black patients through implementation of a ve-year plan
to improve equity. As part of the plan, Wheaton Franciscan conducted a series of focus groups. With
this patient input, Wheaton Franciscan chose to develop a community health worker program led by
someone from the local communityan example of how letting patients and communities be heard
can speed culture change and win support for equity improvement initiatives.
1 2012 National Healthcare Disparities Report. Washington: Agency for Healthcare Research and Quality, May 2013.
2 ibid.
3 ibid.
4 U.S. Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century from Now, U.S.
Census Bureau, December 12, 2012. https://www.census.gov/newsroom/releases/archives/population/cb12-243.html
5 The State of Urban Health: Eliminating Health Disparities to Save Lives and Cut Costs. Washington: National Urban League
Policy Institute, 2012.
6 Finbinder LC and Schulman KA. The Effect of Race on the Referral Process for Invasive Cardiac Procedures. Medical
Care Research and Review 57(1s):16277, 2000. http://mcr.sagepub.com/content/57/4_suppl/162.abstract
7 Fisher T, Burnet DL, Huang ES, et al. Cultural Leverage: Interventions Using Culture to Narrow Racial Disparities in
Health Care. Medical Care Research and Review 64 (5s): 243S82S, 2007.
8 Houston TK, Allison JJ, Sussman M, et al. Culturally Appropriate Storytelling to Improve Blood Pressure: A Randomized
Trial. Annals of Internal Medicine 154(2):7784, 2011.
Working so closely with
our Somali patients has
raised our awareness
of how necessary it is
to hear from each
patient population
about what they think
is most important.
It reminds us of the
necessity of asking
key questions, and of
having patients identify
their own barriers,
desires, and goals.
SHAJUANA SMITH, PA, CDE,
JERICHO ROAD COMMUNITY
HEALTH CENTER, BUFFALO
